Lesson 5 - Neurodevelopmental, Schizophrenia, Bipolar & Depressive Disorders PDF

PSY 056T: ABNORMAL PSYCHOLOGY S ar ah M alaki  LESSON 5: 1. NEURODEVELOPMENTAL DISORDERS; 2. SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS; 3. BIPOLAR AND RELATED DISSORDERS; 4. DEPRESSIVE DISORDERS NEURODEVELOPMENTAL DISORDERS  Neurodevel...

PSY 056T: ABNORMAL PSYCHOLOGY S ar ah M alaki  LESSON 5: 1. NEURODEVELOPMENTAL DISORDERS; 2. SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS; 3. BIPOLAR AND RELATED DISSORDERS; 4. DEPRESSIVE DISORDERS NEURODEVELOPMENTAL DISORDERS  Neurodevelopmental Disorders Video Neurodevelopmental Disorder Flipped Notes by Mandy Rice for AP Psychology - Bing video Introduction Neurodevelopmental disorders are a group of conditions that are characterized by developmental deficits typically diagnosed during infancy, childhood, or adolescence. They manifest impairments of personal, social, academic or occupational functioning. Introduction… These psychological disorders include the following: 1. Intellectual Disability 2. Global Developmental Delay 3. Communication Disorders 4. Autism Spectrum Disorder 5. Attention-Deficit Hyperactivity Disorder (ADHD) 6. Specific Learning Disorder 7. Neurodevelopmental Motor Disorder 1. Intellectual Disability Also known as Intellectual Developmental Disorder was formerly referred to as mental retardation. This type of developmental disorder originates prior to the age of 18 and is characterized by limitations in both intellectual functioning and adaptive behaviors. Limitations to intellectual functioning are often identified through the use of IQ tests, with an IQ score under 70 often indicating the presence of a limitation. Adaptive behaviors are those that involve practical, everyday skills such as self-care, social interaction, and living skills. 2. Global Developmental Delay It is a diagnosis for developmental disabilities in children who are under the age of five. Such delays relate to cognition, social functioning, speech, language and motor skills. It is generally seen as a temporary diagnosis applying to kids who are still too young to take standardized IQ tests. Once children reach the age where they are able to take a standardized intelligence test, they may be diagnosed with an intellectual disability. 3. Communication Disorders Are those that impact the ability to use, understand, or detect language and speech. The DSM-5 identifies four different subtypes of communication disorders: a) language disorder, b) speech sound disorder, c) social (pragmatic) communication disorder. d) childhood onset fluency disorder (stuttering),  4. Autism Spectrum Disorder Autism spectrum disorder is characterized by persistent deficits in social interaction and communication in multiple life areas as well as restricted and repetitive patterns of behaviors. The DSM specifies that symptoms of autism spectrum disorder must be present during the early developmental period and that these symptoms must cause significant impairment in important areas of life including social and occupational functioning. 5. Attention-Deficit Hyperactivity Disorder (ADHD) Attention-deficit hyperactivity disorder is characterized by a persistent pattern of hyperactivity-impulsivity and/or inattention that interferes with functioning and presents itself in two or more settings such as at home, work, school, and social situations. The DSM-5 specifies that several of the symptoms must have been present prior to the age of 12 and that these symptoms must have a negative impact on social, occupational, or academic functioning. 6. Specific Learning Disorder Characterized by difficulties in learning and using academic skills. Could be impairment in reading (Dyslexia); written expression, mathematics (Dyscalculia)  7. Neurodevelopmental Motor Disorder They are characterized by unusual movement and co- ordination. They include: a) Developmental coordination disorder – clumsiness, slowness, poor motor skills. b) Stereotypic movement disorder- repetitive purposeless movement. c) Tic disorders – sudden rapid movements or vocalizations. Tourette’s disorder- A type of Tic disorder characterized by several motor and vocal tics. Treatment/Therapies Skills Training e.g., motor skills. Speech therapy for autism and communication disorders. Family therapy - for family to be supportive. Special Education - for intellectual disability. Physiotherapy – for psychomotor disabilities.  SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS Schizophrenia Spectrum and Other Psychotic Disorders Video Schizophrenia Spectrum & Other Psychotic Disorders (Intro Psych Tutorial #234) - Bing video 9 Kinds of Psychotic Disorders 1. Brief Psychotic Disorder 2. Delusional Disorder 3. (Schizotypal Personality Disorder) 4. Schizophreniform Disorder 5. Schizoaffective Disorder 6. Schizophrenia 7. Catatonia 8. Substance/Medical-Induced psychotic Disorder 9. Psychotic Disorder Due to Another Medical Condition 10. Other Specified Schizophrenia Spectrum and other Psychotic Disorder 11. Unspecified Schizophrenia Spectrum and Other Psychotic Disorder Definition of Terms Psychosis: A severe mental disorder characterized by impairment in thoughts and emotion and often involving a loss of contact with external reality. Schizophrenia: Schizophrenia is a psychological disorder characterized by major disturbances in thought, perception, emotion, and behavior. Hallucinations: Sensations that appear real but are created by your mind. Delusions: Beliefs that conflict with reality. Despite contrary evidence, individuals with delusions can't let go of their convictions. Catatonia: Catatonia is any condition of abnormal motor activity thought to be caused by a psychiatric disorder.  Key Symptoms Positive symptoms: Refers to symptoms that exist in association with a disorder that are not present in normal conditions. The term positive doesn't mean good or beneficial in this instance - it is used in an empirical sense to mean that something is present. Example: hallucinations (tactile, auditory, visual, olfactory and gustatory), delusions, and disordered thoughts or speech. These symptoms are typically considered to be manifestations of psychosis.  Key Symptoms… Negative symptoms: Refer to symptoms that are characterized by their lack of something that should be present. Example - lack of speech (alogia) or action, lack of interest or motivation (avolition), and social isolation - an individual's inability to perform basic, normal functions of living in society, such as- logical thinking, self-care, social interaction, planning, initiating and carrying through constructive actions without a firm understanding of social constructs including apathy, etc. Negative symptoms result in the general inability to complete normal functions of day-to-day life." Key Symptoms… A third category of cognitive symptoms is also included in some descriptions of the disease. Symptoms are further divided by type, including motor, behavioral, and mood disturbances. 1. Brief Psychotic Disorder A. Presence of one of more of the following symptoms; Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior. B. Duration: 1 day – 1 month C. Disturbance is not better explained by major depressive, bipolar disorder or other psychotic disorders. 2. Delusional Disorder A. The presence of one or more delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met (delusions, hallucinations, disorganized speech, disorganized behavior/catatonic, negative symptoms). C. Functioning is not markedly impaired. D. If manic or major depressive episodes have occurred, they have been brief, relative to the duration of the delusional periods. E. Not attributed to substances or other medical condition. 2. Delusional Disorder… Delusional disorder is a psychiatric condition in which the person presents with delusions but no accompanying hallucinations, thought disorder, mood disorder, or significant flattening of affect. Apart from their delusions, people with delusional disorder may continue to socialize and function normally; their behavior does not stand out as odd or bizarre. However, their preoccupation with delusional ideas can disrupt their lives. 2. Delusional Disorder… There are 7 subtypes of delusional disorder: 1. Erotomanic type (erotomania): Delusion that another person, often a prominent public figure, is in love with the individual. 2. Grandiose type: Delusion of inflated worth, power, knowledge, or identity. 3. Jealous type: Delusion that the individual’s sexual partner is unfaithful when such is not the case. 4. Persecutory type: Delusion that the person (or someone the person is close to) is being treated badly or malevolently. 5. Somatic type: Delusion that the person has some physical defect or medical condition. 6. Mixed type: Delusions with characteristics of more than one of the above types but with no single predominant theme. 7. Unspecified type: Delusions that cannot be clearly classified into any of the subcategories.  2. Delusional Disorder… Diagnosis To be diagnosed with a delusional disorder, the individual’s delusions must last for at least one month and cannot be because of a drug, medication, or general medical condition. Delusional disorder cannot be diagnosed in an individual previously correctly diagnosed with schizophrenia. Auditory and visual hallucinations cannot be prominent, though olfactory (smelled) or tactile (felt) hallucinations related to the content of the delusion may be present.  3. Schizotypal Personality Disorder (StPD) Peculiar dress, thinking, beliefs, speech or behavior. Odd perceptual experiences, such as hearing a voice whisper your name. Flat emotions or inappropriate emotional responses. Social anxiety and a lack of or discomfort with close relationships. Indifferent, inappropriate or suspicious response to others. "Magical thinking" — believing you can influence people and events with your thoughts. Belief that certain casual incidents or events have hidden messages meant only for you  4. Schizophreniform Disorder A. Two (or more) of the following; Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms. B. Duration: 1 month- 6 months C. Rule out: schizoaffective, depressive and bipolar disorder with psychotic features. D. Not attributed to substance or another medical condition.  5. Schizoaffective Disorder Schizoaffective disorder is characterized by abnormal thought processes and deregulated emotions; A person with this disorder has features of both schizophrenia and a mood disorder (either bipolar disorder or depression) but does not strictly meet the diagnostic criteria for either. The bipolar subtype is distinguished by symptoms of mania, hypomania, or mixed episodes; the depressive subtype is distinguished by symptoms of depression only. 5. Schizoaffective Disorder… Symptoms Common symptoms of schizoaffective disorder include; hallucinations, paranoid delusions, and disorganized speech and thinking. 5. Schizoaffective disorder… Diagnosis The DSM-5 distinguishes schizoaffective disorder from psychotic depression or psychotic bipolar disorder by additionally requiring that a psychotic condition must last for at least two continuous weeks without mood symptoms (although a person may be mildly depressed during this time). Two episodes of psychosis (an increase from one episode in the DSM-IV) must be experienced in order for the person to qualify for this diagnosis. 6. Schizophrenia Schizophrenia is a disorder of psychosis in which the person’s thoughts, perceptions, and behaviors are out of contact with reality. In informal terms, one who suffers from a psychotic disorder (that is, has a psychosis) is disconnected from the world in which most of us live. About 1% of the population experiences schizophrenia in their lifetime, and usually the disorder is first diagnosed during early adulthood (early to mid-20s). Most people with schizophrenia experience significant difficulties in many day-to-day activities, such as holding a job, paying bills, caring for oneself (grooming and hygiene), and maintaining relationships with others.  6. Schizophrenia… Etiology of Schizophrenia While genetics, environment, neurobiology, and psychosocial stress contribute to schizophrenia, the exact cause of the disease is unknown. A variety of factors have been associated with schizophrenia, including genetic predisposition, environmental factors, and neurotransmitter imbalances. 6. Schizophrenia… Risk Factors & Causes  6. Schizophrenia… Risk Factors & Causes a) Genetic Factors With the advancement of scientific measures such as whole genome sequencing, researchers are able to better understand the genetic factors associated with schizophrenia. Scientists have discovered specific genes (such as VIPR2) and genetic mutations (including copy number variation, or CNV) that are directly related to the disease. If an individual has a family member with schizophrenia, they are more at risk for developing the disorder than an individual without a family history of the disease. 6. Schizophrenia… Risk Factors & Causes b) Environmental Factors Psychosocial environmental stressors can range from parental divorce to suffering from childhood abuse. Individuals who later develop schizophrenia may also be more socially anxious and have emotional fluctuations. It is unclear if these factors exacerbate stressors, are the result of these stressors, or stem from a third variable. The pathenogenic theory of schizophrenia suggests that in-utero exposure to pathogens that affect the central nervous system may cause a predisposition for the development of schizophrenia. Scientists suspect that prenatal exposure to the flu or famine, obstetric complications, central-nervous-system infections in early childhood, and psychosocial stress in childhood and early adulthood may be linked to the disease.  6. Schizophrenia… Risk Factors & Causes c) Neurological Factors Research has shown that neurotransmitter activity is significantly related to schizophrenia. The study of neurotransmitters and schizophrenia is particularly important because most of the pharmaceutical treatment options for the disease involve regulating these chemicals. Dopamine is not the only neurotransmitter associated with schizophrenia, although it can be argued that it is the most studied. Serotonin and glutamate have also been linked with schizophrenia. Increased levels of serotonin are associated with positive symptoms. Glutamate has been theorized to exacerbate hyperactivity and hypoactivity in dopamine pathways, affecting both positive and negative symptoms. 6. Schizophrenia… Symptoms… Symptoms of schizophrenia are categorized as positive or negative; Positive symptoms are disorders of commission, meaning they are something that patients do or think. Examples include hallucinations, delusions, and bizarre or disorganized behavior. Negative symptoms are disorders of omission, meaning they are things patients do not do. Examples include lack of speech, flat affect, anhedonia, asociality, avolition, and apathy. A third category of cognitive symptoms is also included in some descriptions of the disease. 6. Schizophrenia… Symptoms Symptoms are further divided by type, including motor behavioral, and mood disturbances. 6. Schizophrenia… Positive Symptoms Positive symptoms are disorders of commission, meaning they are something that individuals do or think. Examples include hallucinations, delusions, and bizarre or disorganized behavior. Positive symptoms can also be described as behavior that indicates a loss of contact with the external reality experienced by non-psychotic individuals. An example of a positive motor disturbance would be catatonic excitement, which is uncontrolled and aimless motor activity. Positive symptoms tend to be the easiest to recognize. 6. Schizophrenia… Negative Symptoms Negative symptoms are disorders of omission, meaning they are things that the individual does not do. Examples include; alogia (lack of speech), flat affect (lack of emotional response), anhedonia (inability to experience pleasure), asociality (lack of interest in social contact), avolition (lack of motivation), and apathy (lack of interest). Some individuals will experience a catatonic stupor, or a state in which they are immobile and mute, yet conscious. They may exhibit waxy flexibility, where another person can move the patient’s limbs into postures and the patient will retain these postures, like a wax doll. In some cases, negative symptoms can be misinterpreted as depression or laziness. 6. Schizophrenia… Cognitive Symptoms Cognitive symptoms are the most harmful to the livelihood of the individual, as they prevent the individual from participating effectively in the workplace or in society. Cognitive symptoms are subtle differences in cognitive ability that are normally only discovered after neuropsychological tests are given. These include poor ability to absorb and act upon information (executive functioning), lack of attention, and an inability to utilize working memory. 6. Schizophrenia… Motor Disturbances Motor disturbances include disorders of mobility, activity, and volition. People with schizophrenia can exhibit too little (negative) or too much (positive) movement. In addition to catatonic stupor and catatonic excitement, examples of motor disturbances include; stereotypy (repeated, non-goal directed movement such as rocking), mannerisms (normal, goal-directed activities that appear to have social significance, but are either odd in appearance or out of context, such as repeatedly running one’s hand through one’s hair or grimacing), mitgehen (moving a limb in response to slight pressure, despite being told to resist the pressure), ecopraxia (the imitation of the movements of another person), and automatic obedience (carrying out simple commands in a robot-like fashion).  6. Schizophrenia… Behavioral Disturbances Disorders of behavior may involve deterioration of social functioning, such as social withdrawal, self-neglect, or neglect of environment. Behavioral disorders may also involve behaviors that are considered socially inappropriate, such as talking to oneself in public, obscene language, or inappropriate exposure. Substance abuse is another disorder of behavior; patients may abuse cigarettes, alcohol, or other substances. Substance abuse is associated with poor treatment compliance and may be a form of self-medication.  6. Schizophrenia… Mood Disturbances Disorders of mood and affect include: affective flattening, which is a reduced intensity of emotional expression and responsiveness that leaves patients indifferent and apathetic. Typically, one sees unchanging facial expression, decreased spontaneous movements, a lack of expressive gestures, poor eye contact, lack of vocal inflections, and slowed speech. Anhedonia, or the inability to experience pleasure, is also common, as is emotional emptiness. Patients may also exhibit inappropriate affect, such as laughing at a funeral. 6. Schizophrenia… Treatment The primary treatment of schizophrenia is antipsychotic medications, often in combination with psychological and social supports. Hospitalization may occur for severe psychotic episodes either voluntarily or (if mental health legislation allows it) involuntarily. Community support services—such as drop-in centers, visits by members of a community mental-health team, supported employment, and support groups—are common. Some evidence indicates that regular exercise has a positive effect on the physical and mental health of those with schizophrenia. Several psychosocial interventions may be useful in the treatment of schizophrenia, including family therapy, skills training, and psychosocial interventions for substance abuse. Family therapy or education, which addresses the whole family system of an individual, may reduce relapses and hospitalizations.  7. Catatonia Broadly speaking, catatonia is any condition of abnormal motor activity thought to be caused by a psychiatric disorder. For example, individuals with schizophrenia can demonstrate manic patterns of repetitious movement with no purpose, compulsively mimic the sounds or movements of others, or maintain the same posture for a long period of time without moving. In the DSM-5, catatonia is not recognized as its own disorder but rather is listed as a symptom of other psychiatric conditions, such as schizophrenia, bipolar disorder, post-traumatic stress disorder, and depression. 7. Catatonia… Other Catatonic Disorders Catatonia Associated with another Mental Disorder. Catatonic Disorder due to another medical condition. 8. Other Psychotic Disorders Substance/medication-induced psychotic disorder. Psychotic disorder due to another medical condition. Other specified schizophrenia spectrum and other psychotic disorder. Unspecified schizophrenia spectrum and other psychotic disorder. Discussion Questions Compare and contrast Schizophrenia and demon-possession. What is the difference between hearing from God and hearing voices? What is the role of religion in dealing with schizophrenia and other psychotic disorders? Conclusion BIPOLAR AND RELATED DISORDERS  Bipolar and Related Disorders Bipolar disorder (depression & mania) - causes, symptoms, treatment & pathology - Bing video  Bipolar Disorders Bipolar disorders are described by the (DSM-5) as a group of brain disorders that cause extreme fluctuation in a person’s mood, energy, and ability to function. Bipolar disorder is a category that includes three different condition: 1. Bipolar I Disorder - a manic-depressive disorder that can exist both with and without psychotic episodes. 2. Bipolar II Disorder - consists of depressive and manic episodes which alternate and are typically less severe and do not inhibit function. 3. Cyclothymic Disorder - a cyclic disorder that causes brief episodes of hypomania and depression.  Bipolar Disorders… People who live with bipolar disorder experience: periods of mania - great excitement, overactivity, delusions, and euphoria. periods of depression - feelings of sadness and hopelessness. As such, the use of the word bipolar reflects this fluctuation between extreme highs and extreme lows. The diagnosis is frequently assigned to young patients presenting with a (first) major depressive episode. In these cases, diagnosis is exclusively based on psychiatric history provided by family and caregivers, not on the current psychopathological assessment by the psychiatrist.  Bipolar Disorders… Individuals with bipolar disorder experience mood swings that are less severe in intensity. During a hypomanic episode, a person may experience elevated mood, increased self-esteem, and a decreased need for sleep. In a manic episode, these symptoms are not so severe as to impact daily functioning or cause psychotic symptoms. What’s more, in some cases, a bipolar episode can include symptoms of both mania and depression; this is what’s known as an episode with mixed features. Bipolar Disorders… People experiencing an episode with mixed features may feel extreme sadness, guilt, and worthlessness, while at the same time experiencing high energy, racing thoughts and speech, and overactivity. It is not uncommon during a mixed episode for a person to go from being exuberantly happy to be expressing suicidal thoughts in a matter of moments. Bipolar Disorder DSM-5 Diagnostic Criteria To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania. To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day. Bipolar Disorder DSM-5 Diagnostic Criteria During this period, three or more of the following symptoms must be present and represent a significant change from usual behavior: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. Increased talkativeness 4. Racing thoughts 5. Distracted easily 6. Increase in goal-directed activity or psychomotor agitation 7. Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees. Bipolar Disorder DSM-5 Diagnostic Criteria… The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life.  Bipolar Disorder DSM-5 Diagnostic Criteria… The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode: 1. Depressed mood most of the day, nearly everyday. 2. Loss of interest or pleasure in all, or almost all, activities. 3. Significant weight loss or decrease or increase in appetite. 4. Engaging in purposeless movements, such as pacing theroom. 5. Fatigue or loss of energy. 6. Feelings of worthlessness or guilt. 7. Diminished ability to think or concentrate, or indecisiveness. 8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt Treatment Options for Bipolar I & II Pharmacologic: Mood stabilizers Atypical antipsychotic Typical antipsychotic Alternative antipsychotic Neuroleptic Other neurologic Benzodiazepine Antidepressants Education to recognize and manage early symptoms. Psychotherapies: Cognitive behavioral therapy Family-focused therapy Interpersonal social rhythm therapy Psychoeducation Electroconvulsive therapy (ECT) DEPRESSIVE DISORDERS Depressive Disorders Video Depressive Disorders (Intro Psych Tutorial #236) - Bing video Depressive Disorders Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder Premenstrual Dysphoric Disorder Substance/Medication Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder 1. Disruptive Mood Dysregulation Disorder (DMDD) Essential feature: Severe temper outbursts with underlying persistent angry or irritable mood Temper outburst frequency: Three or more time a week Duration: Temper outbursts and the persistently irritable mood between outbursts lasts at least 12 months Severity: Present in two settings and severe in at least one Onset: Before age 10 but do not diagnose before age 6. Cannot diagnose for the first time after age 18. Common rule-outs: Bipolar disorder, intermittent explosive disorder, depressive disorder, ADHD, autism spectrum disorder, separation anxiety disorder, Substance, medication or medical condition If ODD present, do not also diagnose it 1. Issues with DMDD Was it ready for prime time? What are the treatment implications? No empirically supported treatments Avoid bipolar medications Consider CBT treatments used for depression in children: Coping skills for thoughts, feelings and behavior Parent training Parent support group  2. Major Depressive Disorder (MDD) Essential features: Either depressed mood or loss of interest or pleasure plus four other depressive symptoms. Duration: At least two weeks Common rule outs: Medical condition, medications, substance use, bipolar disorder, or a psychotic disorder Note: Be careful about diagnosing major depression following a significant loss because normal grief “may resemble a depressive episode.”  2. Diagnosing MDD Essential Diagnostic Criteria: Meets criteria for a Major Depressive Episode No history of a Manic or Hypomanic Episode Coding Steps: 1. Start with noting whether it is: Major Depressive Disorder, single episode Major Depressive Disorder, recurrent episodes 2. State the severity/course specifier term after single or recurrent episode: Mild, moderate, severe, with psychotic features and in full or partial remission. 4. Now add any of available specifiers (see next slide) 2. Specifiers for Major Depressive Disorder* With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features or with mood-incongruent psychotic features With catatonia (code separately) With peripartum onset With seasonal pattern *See pages 184-188 of DSM-5  Practice Guidelines for MDD (APA, 2010) If the MDD is in the mild to moderate range, use either psychotherapy or meds. – Indications for psychotherapy: Significant stressors Interpersonal problems Patient preference Pregnant, lactating or wish to become pregnant Personality Disorder traits – Indications for medication: Prior positive response Somatic symptoms Patient preference If the MDD is in the moderate to severe range or is complicated by specifiers, use a combination. 3. Persistent Depressive Disorder (Dysthymia) Essential feature: Depressed mood plus at least two other depressive symptoms. Duration: The symptoms persist for at least two years (one year for children and adolescents). May include periods of major depressive episodes (double depression). Rule outs: Be sure it is not due to another psychotic disorder, substance, medication or medical condition 3. PDD: Chronic Depressive Spectrum Chronic MMD Double Dysthymia Depression PDD  3. Specifiers for PDD Severity: Mild, moderate or severe Remission status: In partial or full remission (if applicable) Onset: Early (before 21) or late (21 or older) onset Specify mood features: With anxious distress, mixed features, melancholic features, atypical features, mood- congruent or mood- incongruent psychotic features, and peripartum onset Course specifiers: With pure dysthymic syndrome With persistent major depressive episode With intermittent major depressive episodes, with current episode With intermittent major depressive episodes, without current episode  4. Premenstrual Dysphoric Disorder (PMDD) Essential feature: Significant affective symptoms that emerge in the week prior to menses and quickly disappear with the onset of menses. Symptom threshold: At least five symptoms which include marked affective lability, depressed mood, irritability, or tension. Duration: Present in all menstrual cycles in the past year and documented prospectively for two menstrual cycles Impairment: Clinically significant distress or impairment. Rule outs: An existing mental disorder (e.g., MDD), another medical condition (e.g., migraines that worsen during the premenstrual phase) or substance or medication use.  4. PMDD Update What’s the difference between PMDD and PMS? Why is it clinically significant to note from a mental health stand-point? Increased risk of postpartum depression. Increased risk of suicidal thinking, planning and gestures. Impact on the individual’s quality of life. Impact on psychosocial functioning. 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Retrieved from http://link.springer.com/article/ 10.1023/A%3A1022398104353 Stable National Coordinating Council. (2007). Stable resource toolkit. Retrieved from http://www.integration. samhsa.gov/images/res/STABLE_toolkit.pdf https://www.psycom.net/bipolar-definition-dsm-5/ Thank you www.daystar.ac.ke